Time Flies

Accredited HME companies have several human resource tasks that they are required to perform throughout the year, such as documenting orientation, having job descriptions and evaluating staff competency. Another item that is required is conducting an annual performance evaluation for staff members who have been employed for more than one year. (Depending on the accreditor, some allow small providers to conduct these evaluations every two years rather than each year. )

Providers can choose to perform this process either once annually during a fixed period for all staff, regardless of their hire date; or at each employee’s individual anniversary date.

Many providers prefer to conduct evaluations once a year during a fixed period of time. While some stress that it’s a burden to get the evaluations accomplished within a few weeks, they are happy to have that task completed and off of their to-do list for the remainder of the year.

It’s common for providers to conduct these annual evaluations at the beginning of the year. January and February work well for this process as these months are generally not popular vacation months and, thus, all staff are available. In the spring and summer with vacations and in the fall with back-to-school and the holidays, performing evaluations can feel much more cumbersome.

The burden is to pick a month or timeframe and stick to it. If you let this slip, it can be impossible to catch up quickly.

One of the first questions asked by providers who perform once-a-year evaluations for all is “How do I handle employees who have not been employed for at least year?” My best advice is to go ahead and conduct the evaluations of those staff members, but only for those who have been employed for more than three months. You should identify that the evaluation is not actually an annual evaluation but only for the particular timeframe applicable to that staff member. This way, the evaluation is completed and the staff member will be “caught up” next year when it is time to perform the evaluations again.

Other providers prefer to conduct annual evaluations at the anniversary date of the employee. If you have a large number of employees, this method may be impossible, since you could be conducting evaluations every month unless you have dedicated human resources staff. This method is much better suited for smaller providers who prefer to conduct these evaluations once the employee has been on staff for a full year and who do not have large numbers of employees.

Regardless of the method, you need to ensure that you are meeting your accreditor’s requirements. Your accreditor’s standards may state that you evaluate employees based on the requirements of their job duties and tasks. This is best accomplished by using standardized evaluation tools that “match” tasks itemized on the employee’s job description. The best tools also offer an opportunity for the employee to provide a self-evaluation with the review of the supervisor.

For example, if the employee’s job description lists the requirement to participate in the provider’s on-call program, this is what the matching item might look like:

1. Assume on-call responsibilities during non-business hours in accordance with company policy

   Employee	5	4	3	2	1
   Supervisor	5	4	3	2	1

This meets the requirement to evaluate the staff member by task and offers both the employee and the supervisor the opportunity to rate performance of this task on a scale of 1-5.

Many accreditors also require that your evaluation tool offer a place for the employee to sign and date the review in order to document that he or she has seen it and that it was performed at the appropriate date. The best tools also have a place to document any disagreement with findings and, in the event of poor performance, to describe a plan for continued progress. This is yet another reason to have a good policy and procedure manual so that you have access to quality forms and tools that meet both CMS’ and your accreditor’s requirements.

Read more Accreditation Now columns.

Mary Ellen Conway, RN, BSN, is president of Capital Healthcare Group, LLC, Bethesda, Md., which provides health care management expertise in accreditation preparation and survey follow-up, operations assistance, design of quality improvement programs and outcome measures. She can be contacted by phone at 301/896-0193 or through www.capitalhealthcaregroup.com.